EIN: 841085822
UEI: CH8MR5ENJKZ1
Data as of August 20, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 19, 2026. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by December 19, 2026 (121 days from today).
What is a management decision? →Federal Agency: US Department of Health and Human Services Federal Program: Congressionally Delegated Spending for Construction Projects AL Number: 93.493 Award Period: 1/1/25 – 12/31/25 Type of Finding: Significant deficiency in Internal Control Over Compliance and Compliance Criteria or Specific Requirement 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context During our testing over Suspension and Debarment, noted one instance in which the Organization was unable to locate documentation that a suspension and debarment check was performed prior to entering into a transaction with a vendor. Effect Noncompliance results in possible Federal funds provided to ineligible vendors. Questioned Costs None identified. Cause The Organization does not have internal controls in place to ensure compliance with Federal regulations or the terms and conditions of the Federal award. Recommendation We recommend the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Views of Responsible Officials The Organization acknowledges that, in one instance, documentation evidencing that a suspension and debarment check was performed prior to engaging a vendor could not be located. While this appears to be an isolated occurrence, we recognize the importance of maintaining complete and auditable documentation to demonstrate compliance with 2 CFR Part 200 requirements. In response, the Organization has strengthened its internal controls to ensure that all vendors are properly screened and that such screenings are consistently documented. We have implemented the use of a compliance monitoring system (Compliatric), which maintains a centralized vendor registry and performs monthly screenings against federal exclusion and debarment databases, including SAM.gov and OIG exclusion lists. This system provides an auditable log of all screening activity. These enhanced controls were implemented effective June 9, 2025. Additionally, the Organization has completed a retrospective review of all active vendors to confirm that appropriate suspension and debarment screenings have been performed and documented. Going forward, any potential matches identified through the screening process will be escalated to the Risk and Compliance Manager and/or CFO for review and validation. If a match is confirmed, the Organization will immediately discontinue use of the vendor and terminate the relationship in accordance with federal requirements.
Federal Program: Congressionally Delegated Spending for Construction Projects Assistance Listing No. 93.493 Recommendation: Our auditors recommend the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization acknowledges that, in one instance, documentation evidencing that a suspension and debarment check was performed prior to engaging a vendor could not be located. While this appears to be an isolated occurrence, we recognize the importance of maintaining complete and auditable documentation to demonstrate compliance with 2 CFR Part 200 requirements. In response, the Organization has strengthened its internal controls to ensure that all vendors are properly screened and that such screenings are consistently documented. We have implemented the use of a compliance monitoring system (Compliatric), which maintains a centralized vendor registry and performs monthly screenings against federal exclusion and debarment databases, including SAM.gov and OIG exclusion lists. This system provides an auditable log of all screening activity. These enhanced controls were implemented effective June 9, 2025. Additionally, the Organization has completed a retrospective review of all active vendors to confirm that appropriate suspension and debarment screenings have been performed and documented. Going forward, any potential matches identified through the screening process will be escalated to the Risk and Compliance Manager and/or CFO for review and validation. If a match is confirmed, the Organization will immediately discontinue use of the vendor and terminate the relationship in accordance with federal requirements.
Federal Agency: US Department of Health and Human Services Federal Program: Congressionally Delegated Spending for Construction Projects Pass-Through Agency: N/A AL Number: 93.493 Award Period: 1/1/25 – 12/31/25 Type of Finding: Significant deficiency in Internal Control Over Compliance and Compliance Criteria or Specific Requirement 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context During our testing over Procurement noted two instances in which the Organization was unable to locate documentation that agreements with vendors related to the infrastructure project included the Buy America domestic preference provisions in each agreement, or obtained a BABA (Build America, Buy America) waiver. Effect Noncompliance results in possible federal funds provided to ineligible vendors. Questioned Costs None identified. Cause The Organization does not have internal controls in place to ensure compliance with Federal regulations or the terms and conditions of the Federal award. Recommendation We recommend the Organization implement a process to ensure that procurement agreements with vendors related to infrastructure projects include the Buy America domestic preference provisions in each agreement, or a process to obtain a BABA (Build America, Buy America) waiver. Views of Responsible Officials The Organization was unable to locate documentation demonstrating that procurement agreements included the required Buy America (BABA) provisions or evidence of an approved waiver. In response, the Organization has implemented enhanced internal controls to ensure compliance going forward, including updates to the Procurement Policy to require inclusion of Buy America provisions or documented waivers in all applicable contracts, standardized contract templates with all required federal clauses, and a mandatory pre-award compliance checklist to verify inclusion of these elements. Additionally, procurement documentation is now maintained in a centralized system to ensure proper retention and accessibility, staff have been trained on these requirements, and ongoing compliance is monitored through quarterly reviews and required pre-execution approval for all federally funded contracts. These corrective actions have been implemented and are currently in effect.
Federal Program: Congressionally Delegated Spending for Construction Projects Assistance Listing No. 93.493 Recommendation: Our auditors recommend the Organization implement a process to ensure that procurement agreements with vendors related to infrastructure projects include the Buy America domestic preference provisions in each agreement, or a process to obtain a BABA (Build America, Buy America) waiver. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization was unable to locate documentation demonstrating that procurement agreements included the required Buy America (BABA) provisions or evidence of an approved waiver. In response, the Organization has implemented enhanced internal controls to ensure compliance going forward, including updates to the Procurement Policy to require inclusion of Buy America provisions or documented waivers in all applicable contracts, standardized contract templates with all required federal clauses, and a mandatory pre-award compliance checklist to verify inclusion of these elements. Additionally, procurement documentation is now maintained in a centralized system to ensure proper retention and accessibility, staff have been trained on these requirements, and ongoing compliance is monitored through quarterly reviews and required pre-execution approval for all federally funded contracts. These corrective actions have been implemented and are currently in effect.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on April 24, 2025. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by October 24, 2025, which was (300 days ago).
What is a management decision? →Criteria or Specific Requirement Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one visit where a sliding fee application could not be found to support the slide provided. Effect Potential that a patient would not receive the appropriate sliding fee discount. Questioned Costs None identified. Cause Clerical error in which the sliding fee application was not saved in the patients file. Recommendation We recommend the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Views of Responsible Officials Management agrees that this was a clerical error and an isolated incident. To improve the process and minimize errors, eligibility applications will now be processed at the Grand Junction, Colorado office by a different eligibility staff. This team will enter applications into the electronic medical record system and maintain either paper or digital copies for one year to ensure no applications are lost. This new procedure will provide an additional safeguard in the application process.
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees that this was a clerical error and an isolated incident. To improve the process and minimize errors, eligibility applications will now be processed at the Grand Junction, Colorado office by a different eligibility staff. This team will enter applications into the electronic medical record system and maintain either paper or digital copies for one year to ensure no applications are lost. This new procedure will provide an additional safeguard in the application process.
2023-001
Criteria or Specific Requirement 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context During our testing over suspension and debarment, we noted one instance in which the Organization was unable to locate documentation that a suspension and debarment check was performed prior to entering into a transaction with a vendor. Effect Noncompliance results in possible federal funds provided to ineligible vendors. Questioned Costs None identified. Cause The Organization does not have internal controls in place to ensure compliance with federal regulations or the terms and conditions of the federal award. Recommendation We recommend the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Views of Responsible Officials The Organization has a program called Compliatric that the Organization can load all of its vendors into and it will check on a monthly basis the registries for Debarment and Exclusions from Federal Programs with a log to track this screening. The Organization has changed the accounts payable process to include adding all new vendors to the Compliatric list for screening compliance. The Organization feels this will ensure ongoing compliance of all vendors on a monthly basis going forward. Any matches will require either the Risk and Compliance Manager or the CFO to review and validate the match or identify that the match is an error. If validation is found to be correct all purchasing and use of that vendor will be terminated going forward.
Federal Program: Covid-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing No. 21.027 Recommendation: Our auditors recommended the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has a program called Compliatric that the Organization can load all of its vendors into and it will check on a monthly basis the registries for Debarment and Exclusions from Federal Programs with a log to track this screening. The Organization has changed the accounts payable process to include adding all new vendors to the Compliatric list for screening compliance. The Organization feels this will ensure ongoing compliance of all vendors on a monthly basis going forward. Any matches will require either the Risk and Compliance Manager or the CFO to review and validate the match or identify that the match is an error. If validation is found to be correct all purchasing and use of that vendor will be terminated going forward.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on May 2, 2024. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by November 2, 2024, which was (656 days ago).
What is a management decision? →Criteria or Specific Requirement Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified two visits where a sliding fee application could not be found to support the slide provided. We noted that both visits selected by our random sample were related to the same patient. Effect Potential that a patient would not receive the appropriate sliding fee discount. Questioned Costs None identified. Cause Clerical error in which the sliding fee application was not saved in the patients file. Recommendation We recommend the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Views of Responsible Officials Management agrees that this is a clerical error and an isolated incident. Currently, eligibility staff receives completed applications, scans them into the electronic health record, and discards the hard copy. To minimize error, the procedure will be changed, whereby staff maintains hard copies for the week, and at the end of the week verifies that all applications have been scanned into the system. This will act as a double check of the scanning process.
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization agrees that this is a clerical error and an isolated incident. Currently, eligibility staff receives completed applications, scans them into the electronic health record, and discards the hard copy. To minimize error, the procedure will be changed, whereby staff maintains hard copies for the week, and at the end of the week verifies that all applications have been scanned into the system. This will act as a double check of the scanning process. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Jeremy Carroll, CFO at 832-443-7395.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on April 4, 2022. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by October 4, 2022, which was (1416 days ago).
What is a management decision? →2021-001: PROCUREMENT Federal Agency: U.S. Department of Health and Human Services Program Title: Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services CFDA Number: 93.224 and 93.527 Award Number: H80CS28356 Award Period: January 1, 2021 ? December 31, 2021 Type of Finding: Significant Deficiency in Internal Control over Compliance and Compliance Condition In two of the five samples tested, documentation was not provided to support procurement compliance and control requirements being properly followed. Criteria Per 2 CFR 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements (the Uniform Guidance), section 200.318 General Procurement Standards, the nonfederal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to the following: rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Effect The finding indicates that there could be some process improvement in how contracts are reviewed, documented, and maintained to evidence that compliance requirements are being met. Cause The Organization?s processes and policies are inconsistently applied. Context The Organization did not provide support for evidence of compliance and control with procurement requirements, or support provided indicated noncompliance. Two of the five samples did not contain evidence that procurement policies were properly followed as required. Recommendation We recommend the Organization develop a more robust internal control that monitors the workflow of contract processing surrounding procurement to ensure compliance requirements are met. Management?s Response Management understands the nature of the finding based on the auditor's interpretation of the Organization's procurement policy. Management agrees that documentation was not provided for two of the samples tested. However, management disagrees with the cause of these findings. The Organization consistently applies procurement processes and policies, but the procurement policy is subject to interpretation in one respect. The procurement policy references purchases of $5,000 or more requiring three quotes, an RFP process, or justification for a sole source. The Organization has consistently applied a $5,000 limit per item, not per Purchase Order. While the procurement policy does not specifically define the $5,000 limit, management believes we comply with federal guidance on procurement as well. Management believes we have consistently applied the policy to single items. With respect to the finding and after discussion with the auditors, Marillac will work to resolve this issue going forward by clarifying the procurement policy as follows (or as defined by Marillac's Board of Directors): ? The policy will be changed to identify micro-purchases in aggregate of less than $10k does not require multiple bids or solicitation ? The policy will be changed to identify small purchases in aggregate of greater than $10k and less than $150k require at least 3 bids/quotes from qualified sources ? The policy will be changed to identify purchased in aggregate of greater than $150k requiring publicly solicited bids or competitive proposals ? Note: Sole Source is acceptable for purchases if one of the below circumstances arises: o The item is available only from a single source o The public exigency or emergency for the requirement will not permit a delay resulting from competitive solicitation o The federal awarding agency expressly authorizes noncompetitive proposals in response to a written request from the non-federal entity; or o After solicitation of a number of sources, competition is determined inadequate.
Recommendation: Our auditors recommend the Organization develop a more robust internal control that monitors the workflow of contract processing surrounding procurement to ensure compliance requirements are met. Explanation of disagreement with audit findings: The Organization disagrees with the auditors interpretation of the application of the procurement policy. The Organization has applied it based on per item basis, whereas the auditor interprets it to be on a per contract basis. Action taken in response to finding: Management understands the nature of the finding based on the auditor's interpretation of the Organization's procurement policy. Management agrees that documentation was not provided for two of the samples tested. However, management disagrees with the cause of these findings. The Organization consistently applies procurement processes and policies, but the procurement policy is subject to interpretation in one respect. The procurement policy references purchases of $5,000 or more requiring three quotes, and RFP process, or justification for a sole source. The Organization has consistently applied a $5,000 limit, management believes we comply with federal guidance on procurement as well. Management believes we have consistently applied the policy to single items. With respect to the finding and after discussion with the auditors, Marillac will work to resolve this issue going forward by clarifying the procurement policy as follows (or as defined by Marillac's Board of Directors): The policy will be changed to identify micro-purchases in aggregate of less than $10k does not require multiple bids or solicitation. The policy will be changed to identify small purchases in aggregate of greater than $10k and less than $150k require at least 3 bids/quotes from qualified sources. The policy will be changed to identify purchased in aggregate of greater than $150k requiring publicly solicited bids or competitive proposals. Note: Sole Source is acceptable for purchases if one of the below circumstances arises: The item is available only from a single source. The public exigency or emergency for the requirement will not permit a delay resulting from competitive solicitation. The federal awarding agency expressly authorizes noncompetitive proposals in response to a written request from the non-federal entity' or After solicitation a number of sources, competition is determined inadequate. Name(s) of the contact person(s) responsible for corrective action: Jeremy Carroll, CFO. Planned completion date for corrective action plan: Fiscal year 2022. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Jeremy Carroll at 832-443-7395.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 26, 2020. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by September 26, 2020, which was (2154 days ago).
What is a management decision? →Condition During testing, it was noted that the Organization did not have adequate internal controls designed to ensure that patients were appropriately receiving sliding fee discounts. Criteria As required by 42 United States Code (USC) Part 254, the Organization must prepare and maintain a schedule of fees or payments for the program income provision of its services with a discount schedule applied according to the patient?s ability to pay as determined by the Department of Health and Human Services official poverty guidelines. The Organization should have internal controls designed to ensure compliance with that provision. Effect The Organization?s application of the sliding fee discounts could inadvertently under or over charge eligible patients. Cause The Organization?s processes and policies are inconsistently applied due to human error. Context Two of the forty sliding fee discounts that were tested were provided to patient?s that did not have a sliding fee application on file to support receiving the sliding fee discount. Questioned Costs None. Recommendation We recommend the Organization review policies and processes for providing sliding fee discounts to patients and provide additional training. We would also recommend the Organization consider the review of patient sliding fee eligibility as part of the Organization?s ongoing quality control monitoring. Management?s Response On October 17, 2019, the Organization entered into an agreement to outsource insurance verification accuracy in eClinicalWorks (eCW). These services will provide the following verifications for registration and patient check-in: ? Verify insurance accuracy in eCW account set up ? Verify insurance eligibility for scheduled medical and behavioral health visits in eCW ? Add financial notes related to patient co-pays and past balances to collect at time of visit ? Update insurance coverage as necessary based on eligibility verification results (including Marillac Health Sliding Fee Program) ? Utilize State Medicaid portal to verify any coverage for patients with Sliding Fee or Self Pay status on their account These new services address the finding of sliding fee discounts being applied to expired sliding fee patients. These new checks ensure discounts are applied to active sliding fee discount program participants. These services were implemented on October 17, 2019 and have proven to be effective.
Consolidated Health Centers Grant - CFDA No. 93.224 and 93.527 Recommendation: Our auditors recommended the Organization take measures to ensure that appropriate sliding fee rates/categories are used for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: On October 17, 2019, the Organization entered into an agreement to outsource insurance verification accuracy in eCLinicalWorks (eCW). These services will provide the following verifications for registration and patient check-in: ~Verify insurance accuracy in eCW account set up ~ Verify insurance eligibility for scheduled medical and behavioral health visits in eCW ~Add financial notes related to patient co-pays and past balances to collect at time of visit ~update insurance coverage as necessary based on eligibility verification results (including Marillac Health Sliding Fee Program) ~Utilize State Medicaid portal to verify any coverage for patients with Sliding Fee or Self Pay status on their account. These new services address the finding of sliding fee discounts being applied to expired sliding fee patients. These new checks ensure discounts are applied to active sliding fee discount program participants. These services were implemented on October 17, 2019 and have proven to be effective. Name of the contact person responsible for corrective action: Dan Becker, CFO. Planned completion date for corrective action plan: State in fiscal year 2019 and will continue to evaluate through fiscal year 2020. If the Department of Health and Human Services has questions regarding this plan, please call Dan Becker, CFO, at 970-298-1799.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 29, 2018. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by September 29, 2018, which was (2882 days ago).
What is a management decision? →GSA_MIGRATION
GSA_MIGRATION
2016-004
GSA_MIGRATION
GSA_MIGRATION
2016-005
GSA_MIGRATION
GSA_MIGRATION
2016-006
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 13, 2017. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by December 13, 2017, which was (3172 days ago).
What is a management decision? →GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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